Wiki Documenting in EHR


Sauk City, WI
Best answers
Hi all.

I have not been able to find guidelines/regs on this. I hope someone can give me some direction.
With EHR it is so easy for info to be pulled into a note, but there is not always evidence that the provider reviews this info or that it is even pertinent to the current patient visit. In order to choose the level of service, I have been giving credit to the provider for any documentation that is found within the note and above the signature. If reference is made to a separate document (e.g. lab results, xray report) within the note, credit is also given for that, even if the actual report is not copied into the body of the note.
We have one provider who documents "patient instructions" as a separate, signed note, but doesn't always make reference to the separate note in the primary encounter note. This almost always contains elements of his medical decision making. I would like to treat this as an "addendum", but I'm not sure this is appropriate because, looking at the primary encounter note, there is not always an indication that these "patient instructions" exist.
Does anyone have any references relating to this very gray area in EHR documentation? Or can anyone throw out some things to consider when developing a practice policy relating to the inclusion/exclusion of this info when determining e/m levels?
I know this is somewhat vague and most likely a bit confusing, but if there are thoughts out there I would appreciate reading them.

Thanks so much.
Well, there are such guidelines in the form of meaningful use. I see you mentioned the patient education being documented as a note. However, it really should be represented in the patients chart and counted in your EHR for one of your measures. Without seeing your EHR in action, I would ask what kind of system are you using? In other words, is it template based or does it calculate levels (click based)? I work for an EHR system that utilizes templates and it does pull in information from the chart into the note. For instance, if you do a lab or X-ray all of that is pulled into the note through the template based on the Diagnosis. It may be that you need to check to see how the notes for your EHR are set. It could be that it is setup to do all these things in separate notes. You may be surprised that a few clicks under your configuration for the Doctors note settings could be the answer to your issues. I hope this helps you...

Best Wishes,